Cardiovascular disease is now the leading cause of death in pregnant and postpartum women, according to the American College of Obstetricians and Gynecologists.
Cardiomyopathies, hypertensive disorders of pregnancy, stroke or other cardiovascular disease account for 40% of maternal deaths. Meanwhile, the Centers for Disease Control and Prevention reports that 80% of those deaths could have been prevented, noted Ryhm Radjef, MD, who directs the Henry Ford Health Women’s Heart and Cardio-Obstetric program.
Henry Ford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians, and care teams with resources to help drive the future of medicine.
Of particular concern is the rising number of pregnant women with high blood pressure. Hypertensive disorders affect about 15% of women during pregnancy, according to Million Hearts®. A new program at Henry Ford Health aims to address this growing health challenge.
The Heart Healthy Moms program there helps pregnant women with high blood pressure-related disorders manage their symptoms and improve outcomes relating to cardiovascular disease. This unique cardiovascular clinic focuses on postpartum care, offering remote blood pressure monitoring for pregnant patients diagnosed with hypertensive disorders. Patients are referred by the obstetrics inpatient team upon discharge through a specific referral order on the EHR.
In an interview with the AMA, Dr. Radjef discussed the origins of the program, and how it has succeeded in improving blood-pressure control and reducing the incidence of emergency department visits.
Heart disease can hide in pregnancies
Pregnancy is a natural stress test, Dr. Radjef explained. Many changes take place in the cardiovascular system during pregnancy, including blood pressure and vascular resistance changes, stroke volume increases, and rising heart rates. It can “unmask” a lot of cardiovascular problems.
But heart disease can also mimic the signs and symptoms of a normal pregnancy. A patient may have shortness of breath, swollen legs and fatigue, “but those will be exaggerated in heart disease. If you're not able to carry a conversation or just walk flat surfaces, or you have a lot of leg swelling or weight gain that is beyond the expected weight gain of pregnancy, that can pinpoint to heart disease,” Dr. Radjef cautioned.
Lesser-known cardiovascular risks include fertility treatments and starting a period at a later age. Obesity and family history are other, important predispositions for heart problems.
As part of its advocacy to improve maternal health, the AMA has outlined concrete actions that should be taken to reduce and prevent rising rates of maternal mortality and serious or near-fatal maternal morbidity in the U.S.
Guiding care of patients with an app
The COVID-19 public health emergency played a role in developing this mostly virtual heart health clinic.
“I knew we wanted to look more into hypertension because it was the leading cause of all the cardiovascular disease. We knew we needed to start working on blood pressure management after delivery,” said Dr. Radjef.
The public health emergency’s normalization of virtual care inspired her to start the Heart Healthy Moms clinic, with a focus on telehealth.
But the success of this program relies on a strong relationship between cardiology, ob-gyn and maternal-fetal medicine. A multidisciplinary team meeting takes place once a month to discuss patients who are high-risk, all of whom receive a “care companion” app and a Bluetooth enabled blood pressure cuff that automatically links to the Henry Ford Health EHR.
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“All the patient has to do is just check her blood pressure and that goes straight into her medical team inbox,” said Dr. Radjef, noting that BP checks typically take place once a day, if normal. If there’s a discrepancy or if a nurse is still titrating medication, the patient might need to check it twice a day.
The app also alerts patients when it’s time to take medication. If a patient is having severe symptoms, the app creates a pop up message, telling the patient to go to the local emergency department.
Additionally, weekly nurse visits take place to titrate medication and patients have access to their medical team through a direct portal.
“Whether there are new symptoms or abnormal blood pressure monitoring, we are right there for them, which is very different than a usual cardiology clinic,” said Dr. Radjef.
Patients continue with the remote monitoring for three months postpartum.
“We call the first three months the ‘fourth trimester’ of pregnancy. It’s very crucial in terms of cardiac health,” said Dr. Radjef. “If there are other things that we need to follow up on, we will bring them back. But most of the time we transition them to primary care.”
Educating patients on prevention
“Every time we see a patient, we talk about lifestyle and risk factor modifications. We spend a long time discussing diet habits, exercise, weight loss, sleep patterns,” said Dr. Radjef. Other topics may include contraception, depression and mental health.
Risk factor modifications have the potential to change the trajectory of cardiovascular health for these patients, she emphasized.
Such interventions have paid off. In an initial analysis, which spanned from 2023 to 2024, just four of 87 enrolled patients had persistently elevated blood pressure at the one-month postpartum mark.
“At the fourth week we only had eight emergency department visits. Out of the eight, only two were related to blood pressure being elevated. There were no readmissions, no adverse cardiovascular outcomes,” Dr. Radjef said.
The most rewarding part? When a patient who’s on two or three different medications because of uncontrolled hypertension or had several emergency department visits because of blood pressure control, eventually weans off medication, she added.
Expanding the clinic
Looking ahead, Dr. Radjef would like to enroll more patients, catching them even earlier upon discharge to enroll in the program. She’s been working with colleagues to get the word out about the program through radio and television interviews, word of mouth and flyers on the ob-gyn floors at Henry Ford Health.
She’d also like to expand the team to add a dietitian and a social worker to help patients with transportation, child care, food insecurity and most importantly, mental health.
“Cardiovascular health is extremely important. We need to work more on education, increase awareness—both for physicians and our patients—and then we need to get buy-in from leadership to support us in creating these new clinics, because it's never easy,” she said.
Target: BP™, a national initiative co-led by the AMA and American Heart Association, leverages the AMA MAP™ Hypertension program to help care teams organize their approach to providing evidence-based care and helps health care organizations improve and sustain BP control with professional education, practice tools and resources.
Annually, Target: BP recognizes health care organizations by awarding those who have commitment to improvement, adopted evidence-based BP activities, and achieved BP-control rates of 70% or greater among the patients they serve.
